Presentation on theme: "Learning From Defects: An Intervention to Learn from Mistakes"— Presentation transcript:
1 Learning From Defects: An Intervention to Learn from Mistakes David A. Thompson DNSc, MS, RNAssociate Professor Armstrong Institute for Patient Safety and Quality Johns Hopkins University School of Medicine
2 Culture is Important Respecting the wisdom of frontline workers Assessing the context of care:provider teamwork (collaboration),perceptions of management,patient safety normshierarchy
3 Defects are everywhere Joint Commission data show that Communication breakdowns are the leading root cause of:Sentinel EventsMedication ErrorsPerinatal Deaths & InjuriesDelays in TreatmentWrong Site SurgeriesVentilator events
4 % of respondents reporting above adequate teamwork % of respondents reporting above adequate teamwork4
5 Teamwork Disconnect RN: Good teamwork means I am asked for my input MD: Good teamwork means the nurse does what I say
6 Steps of CUSP Educate staff on Science of Safety Identify defects Assign executive to adopt unitLearn from one defect per quarterImplement teamwork toolsThe intervention we used to improve culture and learn from mistakes is the Comprehensive unit based safety program.Pronovost J, Patient Safety, 2005
7 Lesson Learned: Errors are the result of system failures “Every System is Perfectly Designed to Achieve the Results it Does”BataldenThe third lesson from the IOM was that errors are the result of system failures.Batalden explained this concept perfectly when he said, “Every system is perfectly designed to achieve the results it does.”This statement is the most important concept of all--to improve care we must change our systems.Berwick
9 What is a Defect?Anything you do not want to have happen again
10 Problem Solving* First Order Second Order Recovers for that patient yet does not reduce risks for future patientsExample: You go get the supply or you make doSecond OrderReduces risks for future patients by improving work processesExample: You create a process to make sure line cart is stocked*Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72.
11 Step 4: Learning from Mistakes aka Learning from defects What happened?Why did it happen (system lenses) ?What could you do to reduce risk ?How do you know risk was reduced ?Create policy / process / procedureEnsure staff know policyEvaluate if policy is used correctlyPronovost 2005 JCJQI
12 Assessing Defects Staff Safety assessment Please describe how you think the next patient in your unit/clinical area will be harmed.Adverse event reporting systemsSentinel eventsComplicationsInfection ratesMortality and morbidity conferenceClaims data
13 1. What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfoldingTry to understand what they were thinking and the reasoning behind their actions/decisionsTry to view the world as they did when the event occurredReason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990.
14 What Happened? Talk about and understand what happened Complete the “What Happened?” section of the Learning from Defects tool.(10 minutes)
15 2.Why did it Happen?Review the list of factors that contributed to the incident and check off those that negatively contributed and positively contributed to the defectNegative contributing factors are those that harmed or increased risk of harm for the patientPositive contributing factors limited the impact of harm
16 Why did it Happen?Develop lenses to see the system (latent) factors that lead to the eventOften result from production pressuresDamaging consequences may not be evident until a “triggering event” occursReason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990.
17 Why did it Happen? Complete the contributing factors section Items may positively contribute, negatively contribute, or not apply (n/a)These are examples but you may identify factors that are not listed, if so, write down (10 Minutes)
18 Why did it Happen?Review the list of contributing factors and identify the most important factors related to this event.Rate each contributing factor on its importance to this event and future events. (5-10 minutes)
19 3.What will you do to reduce the risk? Safe design principlesStandardize what we doEliminate defectsCreate independent checksMake it visibleSafe design applies to technical and team work
20 What will you do to reduce the risk? Review the 2-5 most important contributing factorsBrainstorm InterventionsDevelop an intervention to defend against the 2-5 most important contributing factorsIdentify the strongest interventions that are feasible.Identify a metric that you can use to measure the impact of the interventionRate each intervention for its ability to mitigate the contributing factor and the teams belief that the intervention will be implemented and executed
21 What will you do to reduce the risk? Select top interventions (2 to 5) and develop intervention planAssign person and task follow-up date(10-15 minutes)
22 Strength of Interventions Weaker ActionsIntermediate ActionsStronger ActionsDouble CheckChecklists/ Cognitive AidArchitectural/physical plant changesWarnings and labelsIncreased Staffing/Reduce workloadTangible involvement and action by leadership in support of patient safetyNew policy, procedure, or memorandumRedundancySimplify the process/remove unnecessary stepsTraining and/or educationEnhance Communication (read-back, SBAR etc.)Standardize equipment and/ or process of care mapAdditional Study/analysisSoftware enhancement/modificationsNew device usability testing before purchasingEliminate look alike and sound- a-likesEngineering Control of interlock (forcing functions)Eliminate/reduce distractionsAdapted from John Gosbee, MD, MS Human Factors EngineeringRemember sometimes a weaker action is your only option.
23 A Medication Error Story 63 year old man with sternal infection transferred to the ICUAllergy to Penicillin noted in chartTreatment includes Piperacillan25 minutes after dose, patient arrestsAntibiotic reaction regarded as likely trigger
24 A Medication Error Story Fax system for orderingmedicationsis brokenNurse gives the patienta medication to which heis allergicNurse borrowsmedication fromanother patientTube systemfor obtainingmedicationsis brokenPatient arrests and diesICU nurse staffing
29 Impact of ICU Nurse Staffing on Outcomes* Fewer ICU nurses associated with increased LOS risk of pulmonary complicationsPulmonary insufficiencyReintubation of tracheaPneumonia*Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001;4:
30 Impact of Pharmacist on Outcomes* Pharmacist participation on daily rounds in the ICU associated with66% reduction in adverse drug events (ADEs)ADEs reduced 10.4/1000 pt days to 3.5Prevent one ADE every 143 patientsLeape*Leape LL, Cullen DJ, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA .1999;282(3):
31 4. How do you know risks were reduced? Did you create a policy or procedure (weak)?Do staff know about policy or procedure?Are staff using the procedure as intended?Behavior observations, audits, Peer assessmentDo staff believe risks were reduced?
32 How do you know risks were reduced? Once interventions have been implemented complete the “Describe Defect” and “Interventions” portion of section IV of the Learning from Defect Tool.Distribute to staff to rate:The effectiveness of the implementationHow effective the intervention has been at reducing reoccurrence of the defect
33 Summarize and Share Findings Summarize findings (Case Summary )Share within your organizationsShare de-identified findings with others in collaborative (pending institutional approval)
34 ACTIONS TAKEN TO PREVENT HARM IN THIS CASE Safety Tips: Label devices that work together to complete a procedure Rule: stock together devices need to complete a taskCASE IN POINT: An African American male ≥ 65 years of age was admitted to acardiac surgical ICU in the early morning hours. The patient was status-post cardiacsurgery and on dialysis at the time of the incident. Within 2 hours of admission to theICU it was clear that the patient needed a transvenous pacing wire. The wire wasThreaded using an IJ Cordis sheath, which is a stocked item in the ICU and standardfor PA caths, but not the right size for a transvenous pacing wire. The sheath thatmatched the pacing wire was not stocked in this ICU since transvenous pacing wiresare used infrequently. The wire was threaded and placed in the ventricle and staffsoon realized that the sheath did not properly seal over the wire, thus introducing riskof an air embolus. Since the wire was pacing the patient at 100%, there was nopossibility for removal at that time. To reduce the patient’s risk of embolus, thebedside nurse and resident sealed the sheath using gauze and tape.SYSTEM FAILURES:OPPORTUNITIES for IMPROVEMENT:Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath.Regular training and education, even if infrequently used, of all devices and equipment.Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity.Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together.Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire.Label wires and sheaths noting the appropriate partner for this device.ACTIONS TAKEN TO PREVENT HARM IN THIS CASEThe bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together.
35 Key Lessons Focus on systems… not people Prioritize Use safe design principlesGo mile deep and inch wide rather than mile wide and inch deepPilot test your solution, follow up.Answer the 4 questions every time!
36 ReferencesPronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40.Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75.Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):